Calloused Hope for the Last COVID Mile and Beyond

Here we are. We’ve said good-bye to 2020 and we are easing into 2021 with beleaguered optimism. At the end of the 2020, I had the privilege of speaking with STAT News’ infectious diseases and global health reporter, Helen Branswell, on the @Risk podcast about the last mile we are travelling with COVID-19. Last mile issues are typically discussed in the context of telecommunications and logistics. The last mile is notoriously difficult, representing the most expensive and time-consuming portion of a journey. When some of us threw up our metaphorical berets like Mary Tyler Moore upon hearing the news of emergency use authorizations of COVID-19 vaccines, it was because we thought developing effective vaccines was the hardest part of ending COVID-19. As it turns out, it may be better understood as the toll for getting onto the last mile highway. As Helen prophetically warns in her December 2020 article on the marvel of COVID-19 vaccines: if we’re not careful, we could fail to take full advantage of the opportunity scientists and governments, pharmaceutical companies and philanthropic foundations have created for us. Helen and I spoke and she wrote about her cautions even before news of new strains circulating in the United Kingdom and in South Africa had surfaced. Yet, this last mile of our COVID-19 journey was always going to be a bumpy ride. So how do we collectively buckle our seat belts?

Reflect on the Journey to this Point

1. Encourage and celebrate transparency and bravery;

2. Keep achieving world firsts;

3. Move faster.

The journey that led to the development of effective vaccines really starts with a brave scientist who dared to share the genome sequencing of SARS-Cov-2. As Zeynep Tufekci describes in detail: the sequencing was published independently in an open-source depository by Yong-Zhen Zhang, a professor at the Shanghai Public Health Clinical Center and School of Public Health, ten days before China acknowledged the severity of the problem by admitting sustained human-to-human transmission and shutting down the city of Wuhan. The week following Zhang’s disclosure, the Moderna vaccine was developed. If there isn’t a science prize instituted in the name of Zhang, I don’t think the world’s philanthropic community is paying close enough attention. We need to reward scientific transparency and bravery, particularly when the costs are so dire, like they are in China. Even outside of the context of autocratic states, we should add the transparency demonstrated by the United Kingdom and South Africa in disclosing the new variants of the virus to the list of brave acts to be celebrated. The downsides are material and we may yet still need more scientific bravery and transparency again before COVID-19 is finished with us.

The development of effective vaccines in such a truncated timeframe was Branswell’s most pleasant surprise in 2020. Moderna and the Pfizer-BioNTech vaccines are today approved and there are likely more to come, including ones that may not carry such stringent cold-chain and other transportation requirements. Up until now, the development of effective vaccines occurred over much longer time frames. This is good news and let’s not lose sight of that as we stare down the challenges that lie ahead. We have flattened the curve before and we have accomplished other never-been-done-before things during this pandemic. We can and will likely need to keep achieving world firsts, starting but perhaps not finishing with vaccinating the world’s population in record time.

While we celebrate our significant accomplishments, many of us around the world are disappointingly drenched in familiar rising COVID waves. We have a dense track record of moving too slowly: to close borders in the early days, to recommend masks, to lockdown, to focus on ventilation, to close schools in the face of new variants, and to overall take COVID-19 sufficiently seriously. Branswell’s biggest disappointing surprise of 2020 was the horrible consanguinity between toxic politics and faulty pandemic management in the United States of America. While not every country is suffering under as failed and fatal politics as the United States, slow responses everywhere are at least in part a sequela of politics done poorly. All signs point to this lethargy persisting. It’s time to get to know your local representative better.

Understand the Specific Challenges

1. Modernize vaccine delivery by getting more clinicians engaged in the vaccination campaign and better vaccination information management;

2. Anticipate and prevent future problems with vaccine rollout;

3. Integrate communications about viral transmission and vaccination.

During our conversation, Helen suggested some of the challenges that lie ahead for efficient and effective vaccine rollout are: insufficient funding to support the significant delivery effort; the fatigue of front-line health care and public health clinicians who we will place heavy reliance on again to deliver the vaccine; the need to conduct more research about the vaccine with respect to its impact on pregnant and lactating women, the length of immunity particular vaccines afford and whether viral shedding continues to be a hazard in vaccinated individuals; poor communications, like calling the American vaccination effort Operation Warp Speed; and the potential for the anti-vaccine movement to derail demand.

Our vaccination efforts are truly a matter of supply chain management, a chain that started with discovery of the effective formulation and ends at your arm. While some may view 2020 as the Year of our Lord COVID, in the parlance of David Foster Wallace’s corporate sponsored time, it was also in large part *brought to us by supply chain disruptions* (SCDs: breakin’ it down when you need it built up the most) like in the case of personal protective equipment, ventilator manufacture, ultra-cold storage freezers, and testing and tracing capacity.

Returning then to our analogy of the last mile in the supply chain space, parcels are still mostly delivered through a small number of delivery agents, like public postal services and a small number of private delivery companies. Last mile delivery is changing quickly though and in the near future, we can anticipate a network of independent couriers and delivery agents connected to a delivery ecosystem picking up and delivering small packages, with cost efficiency improving by using real-time information and capacity.

So far in Canada the challenge has been the overly slow rollout of the vaccine, not reaching the most vulnerable quickly enough. Delivery of the vaccine today in Ontario resembles the early days of postal service. We are currently moving at one-man-on-a-horse-pace serving widely spaced ranches. We are relying on hospitals to lead vaccine efforts and we are limiting the number of transportation legs in strict accordance with recommendations from the manufacturer. We are a hub with limited spokes. This may because of insufficient funding support for the roll-out. It may relate to excessive cautiousness in our approach to the transportation limitations recommended by the manufacturer. Even the necessary paperwork related to consent and authorization can become a tax on velocity when every second counts and so far we have seen no signs yet of implementation of the promised vaccine injuries fund that could serve in part to alleviate this particular burden. All told, the exact causes are not entirely clear and the likely answer is all of the above and then some. What is patently obvious is that the ongoing spikes in COVID-19 cases in many parts of Canada are not helping.

Ultimately, we need our vaccine rollout effort to look more like the future of logistical management and less like the past. We need to get many more clinicians involved in delivering the vaccine — a network of professionals competent to deliver a vaccination injection — rather than exclusively relying on hospitals to do that work. This will become easier to do once vaccines that are single dose or at least more tolerant of regular refrigerator temperatures come online. We also need to get ready to track inoculation at the individual level — real-time information — so that second doses when required can be tracked and delivered in a timely fashion. It’s easy to ignore challenges to demand for the vaccine right now when the main worry is insufficient inventory but that problem can and might flip into insufficient willing arms. Let’s focus on demand issues like anti-vaccination sentiment and vaccine hesitancy before they become a problem. Last, we need to better manage COVID-19 transmission. From a public communications perspective, lockdowns and other heavy public health hammers need to be linked to efficient vaccine roll-out rather than viewed, managed and discussed as siloed efforts. As Dr Tim Evans succinctly puts it: good public behaviors such as physical distancing and mask wearing will need to be sustained in order to counter expectations that immunization permits an immediate return to “normal life”. Stay home. Mask Up. Get vaccinating and vaccinated. Giddy up.

Know Where You’re Headed

1. The goal is elimination;

2. Greater health equity now and thereafter;

3. Work towards a better future.

Where are we collectively going and where do we want to be? The first episode of the @Risk podcast in 2021 is a conversation with Mark Kingwell, University of Toronto Professor of Philosophy and author of On Risk or If You Play, You Pay: Politics of Chance in a Plague Year. One of the themes of On Risk is that we can never entirely eliminate risk, even when we want to. The COVID-19 pandemic is a perfect example. We live with the risk of testing positive by being a human on this planet. A human cannot tap out. For certain, your risk is the least if you live in a place that has very low to zero case numbers, like Taiwan or Nova Scotia for example, and the choices you make even when living in a community with high rates of transmission can dramatically influence your risk to very low levels. But as a human being on this planet, there is no such thing as zero COVID-19 risk at this time. If you play, you pay. If you are alive, you are playing. If you are alive to play, you pay a risk tax. The exact amount of that tax ranges from negligible to fatally high.

At an individual level, we want to be vaccinated to avoid getting ill with COVID-19. But even if we are personally vaccinated, the collective outcome for the human species does not have one clear answer. Elimination of COVID-19 is still possible, although with each passing day of accelerating transmission, together with the possibility of more mutation of the virus, that goal becomes less possible. As Canadian physician Dr. Mike Ryan of the WHO explains: “The existence of a vaccine, even at high efficacy, is no guarantee of eliminating or eradicating an infectious disease. That is a very high bar for us to be able to get over.” If we are unable to eliminate the virus, then our vaccination efforts will result in the virus becoming endemic. According to the U.S. Centre for Disease Control, endemic refers to the constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area. According to Jean-Paul Soucy, a doctoral student in epidemiology at University of Toronto: “I think it’s fair to say that (the COVID-19 virus) will continue to exist somewhere in the world for the foreseeable future … But how much it will directly impact us remains to be seen.” While our exact destination is not known today, we do know the options available to us and that staying home and limiting our contacts today is an investment in eradication as the future outcome. Our political leaders need to talk about this more.

Another theme Kingwell explores is that risk is always political, even while seeming random and fixed. There is a representation of respiratory virus pandemic defence that is numerous swiss cheese slices, one stacked up in front of the other. On the left side of the horizontal stack is the virus and on the right is you. Each slice represents a single intervention, like masks or testing & tracing. The swiss cheese rendering illustrates that no single intervention is perfect — there are holes in the cheese that the virus can pass through — but when many slices are stacked up, the holes don’t align and this prevents transmission by stopping the virus from reaching you. But we don’t all have equal access to each cheese slice. If you are Black or Indigenous in Canada, not all slices of prevention are available to you. You might have to work outside the home making it impossible for you to limit your contacts as much as someone who can work from home. This increases the chances of the virus slipping through an alignment of holes in the cheese to reach you causing infection. The risks of a fatal outcome to you are also greater because when the virus infects a Black person their overall health status may not be as strong as someone with greater access to primary care and healthy food, and this may explain higher mortality rates in Black people. We are off to a more positive start of this last mile by taking these health inequities into account in our approach to population priorities for vaccination. Addressing these health inequities will extend beyond the pandemic. It is a big part of being better prepared for the next one. We should keep that road ahead in mind so we don’t stop too soon.

Kingwell and I ended our conversation and he his treatise discussing “calloused hope” and I’ll do the same with this post. “Calloused hope” is a term coined by Cory Booker describing a kind of hope that is neither cheap nor easy. None of the proposals in this post are cheap or easy. They are informed by the road already travelled, which has resulted in its own callouses. New callouses will be formed as we undertake rigorous assessment and management of the terrain ahead and by considering where to drop a well-considered pin so that we don’t lose sight of where we want to go.

The challenge of all crises and especially of their last mile is that they render absolutely necessary the complex and difficult things that outside of the crisis were likely viewed as aspirational. Get to know your local representatives better. Sympathize with their exhaustion and push them to do better. Share your priorities with them. Support them in working towards prevention of problems rather than waiting to act in response. Act with urgency so they will too. We are headed somewhere, even if exhausted and depleted. Though the bumps will be many, we will reach a destination. I’m grateful to Helen Branswell and Mark Kingwell for their significant contributions towards helping us avoid disappointment upon arrival.